Provider Demographics
NPI:1619161833
Name:CONSOLIDATED YOUTH SERVICES
Entity Type:Organization
Organization Name:CONSOLIDATED YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-972-1110
Mailing Address - Street 1:4220 STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9384
Mailing Address - Country:US
Mailing Address - Phone:870-972-1110
Mailing Address - Fax:870-972-5433
Practice Address - Street 1:4220 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9384
Practice Address - Country:US
Practice Address - Phone:870-972-1110
Practice Address - Fax:870-972-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
AR10011251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1359337Medicaid